Medicare Part B

Updates and Changes 2016/2017

“Presented by Tammy Ewers, CPC

Education and Outreach Representative

DISCLAIMER

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov.

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

May 2016 2

Agenda

• Changes for 2016

• Noridian Medicare Portal

• Enrollment Revalidation Updates

• MACRA Quality Payment Program (QPP)

• Ordering and Referring issues

• Review Contractor Changes

• Resources

May 2016 3

Changes are a Coming !!

May 2016 4

Medicare Beneficiary Identifier (MBI)

• The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires removal of Social Security Numbers (SSNs) from all Medicare cards by April 2019.

• 11-characters in length

• Made up only of numbers and uppercase letters (no special characters)

• All eligible beneficiary will receive a new Medicare card for Medicare transactions like billing, eligibility status, and claim status.

October 2016 5

ICD-10-CM Updates

• Effective October 1, 2016, Noridian’s medical review will look at diagnosis(es) – With highest level of specificity

– “ICD-10 family” no longer acceptable

– Diagnosis appropriate based on documentation

– Does not change current system edits or LCD/NCD policy covered diagnosis(es)

• CMS published resources on ICD-10 follow-up and analyzing claims/data for potential problems – See ICD-10 Next Steps Toolkit at:

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NextStepsToolkit20160226.pdf

October 2016 6

CMS Page for ICD-10 information

October 2016 7

ICD-10 grace period to end: 3 ways to

avoid claim denials

• On October 1, the ICD-10 coding grace period will come to an end and three ways are suggested to assist in avoiding claim denials :

• Be specific: Documentation is used for more than billing

• Pay attention to trends in denials: Denial trends can be early identifiers

• Emphasize ICD-10 codes that focus on quality initiatives: It’s particularly vital for practices to discuss and understand how to use codes to the highest level of specificity, reporting co-morbid conditions when necessary for patients with complex care needs,

October 2016 8

Noridian Medicare Portal

(NMP)

Noridian Medicare Portal Home Page

October 2016 10

NMP Registration Tips

• Ensure Provider Administrator is enrolled before other users attempt to enroll

• Ensure TIN/SSN and NPI combinations in EDISS Connect are correct

• Need Trading Partner ID (EDISS Connect) – Unable to sign into EDISS Connect?

– Call 877 908 8431 (main provider #) or

– http://www.edissweb.com/cgp/contact/

October 2016 11

Self-Service Reopenings Available

Through NMP

• Providers with End User access to the Noridian Medicare Portal (NMP) are able to reopen certain claims within the portal. The End User must be approved for the Appeals functionality by their Provider Administrator. – The following clerical corrections may be made:

– Add, replace or remove diagnosis code

– Add, replace or remove modifier

– Billed in error

– Reprocess claim

– Reopenings are available for claims that meet the following criteria:

– Claim was processed within one year

– Claim is finalized

May 2016 12

Self-Service Reopenings Available

Through NMP continue..

– No Additional Documentation Request (ADR) was sent

– Claim was not reviewed

– Claim was not previously appealed

– Procedure code and modifier are not too complex

– After the reopening has been submitted, End Users may view the adjustment through the Claim Status option after one business day.

• See the User Manual and self-paced tutorial for step-by-step instructions.

May 2016 13

Portal Online Recording

• Video Tutorial completed (18 mins.)

• Education/Schedule of Events (left corner)

October 2016 14

Enrollment

Changes and Revalidations

Noridian's Enrollment Page

October 2016 16

Enrollment Revalidation

• Cycle 2 - https://data.cms.gov/revalidation

– Utilize search tool that will provide Due Date

• Email notice from Noridian within 2-3

months of established due date

• Must submit Revalidation before due date

– Always last day of month

• Note : Special Edition SE1605 provides

additional information

October 2016 17

Enrollment Revalidation

• If TBD listed, due date coming

– Do nothing and only submit Revalidation when due date provided

• Submit application via Internet-based PECOS

• Unsolicited revalidations – more than 6 months will be returned

• Any questions? Contact Enrollment Contact Center

October 2016 18

Revalidation

• Clinic Providers

– Retired

– Left the practice

• 855R application

– Close provider applications

– Prevent fraudulent activities

– Prevent unnecessary correspondence for

revalidation

October 2016 19

Locate Your Date

October 2016 20

Enrolled for Sole Purpose of

Ordering/Referring Services

• Must include statement they are enrolling only to

order and refer and will not be submitting claims

• Complete the CMS-855O

Applicable

physician

and non-

physician

providers

October 2016 21

Enrollment “Appeals”

October 2016 22

MACRA Quality Payment

Program (QPP)

Medicare Access & CHIP

Reauthorization Act (MACRA)

MACRA

• MACRA makes important changes how Medicare pays and ends Sustainable Growth Rate (SGR)

• House Resolution (H.R.) into law 2015 – https://www.congress.gov/bill/114th-congress/ house-bill/2

• Does not apply to hospitals, other facilities or Medicaid – https://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

BIC Oct 2016 24

Consolidation – MIPS/APM

• MACRA consolidates current programs ending December 2018

– Physician Quality Reporting System (PQRS)

– Value-Based Modifier (VM)

– Electronic Health Records/Meaningful Use (EHR-MU)

• January 1, 2019 incentives begin

– Merit-Based Incentive Payment System (MIPS)

– Alternative Payment Model (APM) Eligible Providers start reporting 2017

BIC Oct 2016 25

MACRA Payments

• 2016 – 2019 = .05% annual fee increase

• Holds 2019 payment rates through 2025

• Starting 2019, payment adjustments

– Physician participation in APM/MIPS program

• 2026+ has two payment rates

– APM = 0.75 % increase each year

– Other = 0.25% increase each year

BIC Oct 2016 26

Eligible Providers (EPs)

• Eligible Providers (EPs) include:

– 2019 (MD, DO, DDS, DM, DPM, Optometry,

Chiropractor, PA, NP, CNS and CRNA)

– After 2021, other EPs may be added

• EPs participate in MIPS or APM

– MIPS – provider receives positive, negative or

zero payment adjustment

– APM - provider may receive 5% incentive for

6 years

BIC Oct 2016 27

BIC Oct 2016 28

Quality Payment Program: Pick Your Pace in Year One

Clinicians will pick their pace for the first year – both in how they participate and when. We expect that everyone who is eligible for the Quality Payment Program will participate. We’ve announced four options that we plan to further describe in the final rule:

Test Participation

or

Partial Participation

or

Full Participation

or

Advanced Alternative Payment Models

29 BIC Oct 2016

Merit-Based Incentive Payment

System (MIPS)

or

Alternative Payment Model (APM)

Two Provider Paths To Choose

• Path #1: MIPS

– MIPS requires Composite Performance Score • Incorporates performance on those categories

– May receive upward, downward or no payment (neutral)

• Based on providers performance

– Quality

– Resource use

– Clinical practice improvement activities

– Meaningful use of certified EHR technology

BIC Oct 2016 31

MIPS Point System

• Payment determined two years after performance

Components of the MIPS Score

MIPS scale (0-100 points) Effective January 1, 2019

Advance Care/ Meaningful Use

(25%)

Quality PQRS/VM

(50%)

Cost/ Resource Use

(10%)

Clinical Practice Improvement

(15%)

BIC Oct 2016

Performance Year Payment Year

2017 2019

2018 2020

2019 2021

32

MIPS Performance Categories

• Quality (50 percent of total score in year 1): – Clinicians choose six measures that

accommodate differences among specialties and practices

• Advancing Care Information (25 percent): – Customizable measures that reflect how they use

technology practice

– Emphasis on interoperability and information exchange

– Does not require all-or-nothing EHR or redundant reporting

BIC Oct 2016 33

MIPS Performance Categories 2

• Clinical Practice Improvement Activities (15 percent): – Rewards clinical practice improvements

– Activities on care coordination, beneficiary engagement/patient safety

– Select from a list of more than 90 options

• Cost (10 percent): – Score based on Medicare claims, meaning no

reporting requirements

– Category uses 40 episode-specific measures for specialty differences

BIC Oct 2016 34

Alternative Payment Model (APM)

• Path #2: APMs

– “Qualifying APM participants” not subject to

MIPS adjustments

– Lump sum incentive payment equal to 5%

– CMS sees less than 30% providers in APM

– In 2026, fee schedule growth rate higher for

qualifying APM participants than other

practitioners

BIC Oct 2016 35

APMs Include EHR Technology:

BIC Oct 2016 36

Providers Contact

• QualityNet Help Desk:

– Portal password issues

– PQRS feedback report availability/access

• Individuals Authorized to Access CMS

Computer Services (IACS)

registration/login

– 866-288-8912

– Email qnetsupport@hcqis.org

BIC Oct 2016 37

Ordered and Referred Services

Requirements & Documentation

Reminders and Updates

Orders for Diagnostic Lab Tests

• Order is defined as communication from

treating physician or NPP requesting

diagnostic test be performed

• A physician order is not required to be

signed

– Physician must clearly document, in medical

record his/her intent that test be performed

November 2016 39

Physician Intent

• Order or requisition signed by physician

– Not valid on its own

• Notation in patient’s record is needed

• Verbal/telephone order documented at

treating physician’s office

• Email from physician to be verified

• May need physician signature attestation

November 2016 40

Documentation Requirements

• Maintain in patient medical records

– Orders/communications from ordering

physician/ NPP

• Orders delivered in writing, via phone or emailed

• Additional, conditional tests requested

– Test results

• Record date service was performed

November 2016 41

Signature Requirements

• Unsigned physician orders or unsigned requisitions alone do not support physician intent.

• Physicians should sign all orders for diagnostic services to avoid potential denials.

• If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response.

• Attestation statements are not acceptable for unsigned physician orders/requisitions.

November 2016 42

Insufficient Documentation Errors

• Signatures Missing

• Physician Order Related – Orders Missing

– Orders Unsigned

– Intent to order not included in note

• Documentation to support intent to order (for example, a progress note or office visit note); and

• Documentation to support the medical necessity of ordered services.

November 2016 43

Documentation Requirements Unlisted

Codes

• For unlisted lab codes:

– When billing electronically, Item 19 or

narrative should have:

• Most complete, accurate description

– Don’t be brief

• Lots of characters to explain test performed

– Being descriptive will expedite pricing of

claims

November 2016 44

Quality Testing

• Medicare does not pay for quality testing

perform by labs for the sake of validating

testing methods.

November 2016 45

Claim Review Programs

Supplemental Medical Review

Contractor (SMRC)

• Strategic Health Solutions, LLC – Omaha, NE

• Variety of medical review tasks to lower improper payments

• Medicare or SHS not authorized to reimburse for records printing/mailing

October 2016

https://strategichs.com/smrc/

47

CERT Contractor Update

• 10/07/16- AdvanceMed will be performing all tasks

• All inquiries and records should be sent to

• CERT Documentation Center 1510 East Parham Road Henrico, VA 23228 Fax: 804-261-8100 Customer Service: 443-663-2699 Toll Free: 888-779-7477 Email: certmail@admedcorp.com

•

November 2016 48

CERT Reviews

• Lab- Clinical

• Chiropractic Services ( excessive

numbers)

• Timed Codes ( critical care )

• Ambulance Transports ( non emergent)

• Physical Therapy

• Evaluation and Management - Outpatient

May 2016 49

Recovery Audit Mass Adjustment

October 2016 50

Resources

May 2016 51

CMS How to Use CCI Tools

• Dated April 2015

– Current in Mar. 2016

• 16 page booklet

• Informative, detailed

guide

April 2016 52

Ordering and Referring Fact Sheet

October 2016 53

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